1. Arterial supply to the anus
    inferior rectal artery
  2. venous drainage
    above the dentate is internal hemorrhoid plexus

    below the dentate is external hemorrhoid plexus
  3. Hemorrhoids
    1) left lateral, right anterior, and right posterior hemorrhoidal plexuses

    • 2) External hemorrhoids cause pain when they thrombose
    • - distal to the dentate line, covered by sensate squamous epithelium; can cause pain, swelling, and itching

    • 3) Internal hemorrhoids cause bleeding or prolapse
    • Primary- slides below dentate with strain
    • Secondary- prolapse that reduces spontaneously
    • Tertiary- prolapse that has to be manually reduced
    • Quaternary- not able to reduce

    4) Tx: fiber and stool softeners; sitz baths

    5) Thrombosed external hemorrhoid--> lance open to relieve pain

    • 6) Surgical indications:
    • 1- recurrent disease (bleeding)
    • 2- thrombosis multiple times
    • 3- large external component

    7) can band primary, secondary, and tertiary internal hemorrhoids

    8) surgery needed for some tertiary and quaternary internal hemorrhoids - 3 quadrant resection

    9) need to resect down to the internal sphincter

    10) postop needs sitz baths, stool softener, and high-fiber diet

    11) Do not band external hemorrhoids (painful)
  4. Rectal Prolapse
    1) starts 6-7cm from anal verge

    2) secondary to pudendal neuropathy and laxity of the anal sphincters

    • 3) Increased with:
    • 1- female gender
    • 2- straining
    • 3- chronic diarrhea
    • 4- previous pregnancy
    • 5- redundant sigmoid colons

    4) prolapse involves all layers of the rectum

    • 5) Treatment: high fiber diet
    • 1- rectosigmoid resection (altmier) transanally if patient is older and frail
    • 2- LAR; in the abscence of a large redundant colon or constipation symptoms may perform just rectopexy
  5. Anatomic defects or abnormalities in patients with chronic rectal prolapse:
    • 1) abnormally deep rectovaginal or rectovesical pouch
    • 2) lax and atonic musculature of the pelvic floor
    • 3) lack of normal fixation of the rectum and an elongated mesorectum
    • 4) redundant sigmoid colon
    • 5) lax and atonic anal sphincter
  6. Condylomata Acuminata
    1) cauliflower mass; papillomavirus (HPV)

    2) Treatment: laser surgery
  7. Anal Fissure
    1) caused by a split in the anoderm

    2) 90% in posterior midline

    3) causes pain and bleeding after defecation; chronic ones will see a sentinel pile

    • 4) Medical Tx (90% heal):
    • 1- sitz baths
    • 2- bulk
    • 3- lidocaine jelly
    • 4- stool stoftners

    • Surgical Treatment:
    • 1- lateral subcutaneous internal sphincterotomy

    5) fecal incontinence is the most serious complication of surgery

    6) do not perform surgery secondary to Crohn's disease or ulcerative colitis

    7) lateral or recurrent fissures- worry about inflammatory bowel disease
  8. Anorectal abscess
    1) can cause severe pain

    2) perianal, intersphincteric, and ischiorectal abscess can be drained through the skin (all are below the levator muscles)

    - Intersphincteric and ischiorectal abscesses can form horseshoe abscess

    3) supralevator abscesses need to be drained transrectally

    4) Antibiotics are needed for cellulitis, patient with DM, immunosuppressed, or artificial valve.
  9. Pilonidal cysts
    1) sinus or abscess formation over the sacrococcygeal junction; increased in men

    2) Treatment: drainage and packing; follow-up surgical resection of cyst
  10. Fistula-in-ano
    1) unroof fistula and eliminate the primary opening with rectal advancement flap

    2) do not need to excise the tract

    3) often occurs after anorectal abscess formation

    4) Goodsall's rule- anterior fistulas connect with the rectum in a straight line. Posterior fistulas go toward a midline internal opening in the rectum
  11. Rectovaginal fistulas
    • 1) Simple-
    • 1- secondary to infection or obstetrical trauma
    • 2- low to midvagina
    • 3- <2.5cm

    Treatment: transanally unroof and place rectal mucosa advancement flap

    Many obstetrical fistulas heal spontaneously

    • Complex:
    • 1) secondary to inflammatory bowel disease, XRT, neoplasm, or high in vagina or >2.5cm

    Treatment: abdominal or combined approach usual; resection and reanastomosis with placement of colostomy; need good tissue for anastamosis
  12. Anal incontinence
    1) Neurogenic (gaping hole)- no good treatment

    2) Abdominoperineal descent- damage to levator ani muscle and anus falls below levators, also stretches the pudendal nerves

    • Treatment:
    • 1- high-fiber diet
    • 2- limit to 1 BM/day
    • 3- sphincteroplasty if related to trauma (childbirth)
  13. AIDS and anorectal problems
    • 1) Kaposi's sarcoma-
    • - see nodule with ulceration
    • - most common cancer in patients with AIDS

    • 2) CMV-
    • - see shallow ulcers
    • - similar presentation as appendicitis
    • Treatment- ganciclovir

    3) HSV- #1 rectal ulcer

    • 4) B cell lymphoma- can look like abscess or ulcer
    • - need biopsies of ulcers to rule out cancer
  14. Anal cancer
    1) association with HPV and XRT

    2) anal canal- above dentate line

    3) anal verge- below dentate line

    4) Anal canal lesions (above dentate line)

    • 1- Squamous cell Ca (type of epidermal Ca)
    • Symptoms: pruritis, bleeding, and palpable mass
    • Treatment: Chemotherapy 1st line (Nigro protocol, chemo- 5FU and mitomycin, and XRT), not surgery
    • - if the patient has inguinal adenopathy, need to get FNA- if positive need to extend the radiation field to the inguinal nodes
    • - cures 80%
    • - APR for persistent or recurrent cancer

    • Basaloid (cloacogenic) Ca, mucoepidermoid Ca
    • Treatment: same as squamous cell Ca

    • Adenocarcinoma
    • Treatment- APR usual; WLE if <3cm, <1/3circumference, limited to submucosa (T1), well differentiated, and no vascular/lymphatic invasion, needs about 1cm margin
    • - postoperative chemo/XRT same as rectal Ca

    • Melanoma
    • 1- 3rd most common site for melanoma (skin and eyes #1 and #2)
    • 2- 1/3 has spread to mesenteric lymph nodes
    • 3- hematogenous spread to the liver and the lung is early and accounts for most deaths.
    • 4- symptomatic disease is often associated with significant metastatic disease
    • 5- most common symptom- rectal bleeding
    • 6- most tumors are lightly pigmented or not pigmented at all
    • 7- Treatment: APR usual, margin dictated by depth of lesion standard for melanoma

    Anal Margin lesions (below dentate line)- have better prognosis than anal canal lesions

    • Squamous cell Ca
    • 1- ulcerating, slow growing; men with better prognosis
    • 2- Metastases- go to inguinal nodes
    • 3- Treatment: WLE for lesions <3cm and can get 0.5cm margin
    • 4- may need APR for larger lesions or if sphincter is involved
    • 5- need inguinal node dissection if clinically positive

    • Basal cell Ca
    • 1- central ulcer, raised edges, rare metastases
    • 2- Treatment: WLE usually sufficient, only need 3mm margins; rare need for APR unless sphincter is involved

    • Bowen's disease (malignant)
    • 1- intraepidermal squamous cell Ca
    • 2- many of these patients have or will develop 1 or more primary internal malignancies or will develop a primary cancer of the skin with internal metastases
    • 3- treatment- local therapy, possible WLE with clear margins; check for other internal malignancies

    • Paget's disease
    • 1- intraepidermal apocrine gland Ca
    • 2- slow growing, has positive PAS stain
    • 3- many of these patients have intractable itching
    • 4- many of these patients have or will develop a retal or colon Ca
    • 5- Treatmet- WLE with clear margins; groin dissection for positive nodes; check for other internal malignancies
  15. Nodal Metastases
    • 1- superior and middle rectum- IMA nodes
    • 2- lower rectum- primarily IMA nodes, also to internal iliac nodes
    • 3- upper 2/3 of anal canal- internal iliac and pelvic nodes
    • 4- lower 1/3 of anal canal- inguinal nodes
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